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Medical Nutrition Therapy (MNT) in Non-alcoholic Fatty Liver Disease

Medical Nutrition Therapy (MNT) in Non-alcoholic Fatty Liver Disease. Golaleh Asghari Nutrition and Endocrine Research Center Research Institute for Endocrine Sciences Shahid Beheshti University of Medical Sciences. Introduction. The MNT of NAFLD patients should be based on:

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Medical Nutrition Therapy (MNT) in Non-alcoholic Fatty Liver Disease

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  1. Medical Nutrition Therapy (MNT) in Non-alcoholic Fatty Liver Disease Golaleh Asghari Nutrition and Endocrine Research Center Research Institute for Endocrine Sciences ShahidBeheshti University of Medical Sciences

  2. Introduction The MNT of NAFLD patients should be based on: • Insulin resistance • Metabolic syndrome • Oxidative stress • Dyslipidemia • Cardiovascular risk

  3. Lifestyle recommendations Usual management of NAFLD includes lifestyle counseling to increase physical activity and achieve gradual weight reduction

  4. Lifestyle recommendations Rinella ME et al. Nat Rev Gastroenterol Hepatol 2016, 13, 196–205.

  5. Lifestyle recommendations • Management of weight and overall fitness is the cornerstone of treatment for all patients with NAFLD. • Several studies have demonstrated the benefit of weight loss in reducing steatosis or the NAFLD activity score on histology, with greater weight loss associated with more substantial improvements. Rinella ME et al. Nat Rev Gastroenterol Hepatol 2016, 13, 196–205.

  6. Lifestyle recommendations • Reductions in ALT levels and steatosis occur even with small decreases in weight, whereas resolution of NASH, or even fibrosis, occurs with more marked or sustained weight loss, such as that observed after bariatric surgery Wong VW, et al. J Hepatol 2013, 59: 536–542.

  7. Lifestyle recommendations • A prospective study of 293 patients in a community health-care setting demonstrated the effect of weight loss of varying degrees on NASH histology. • Monitored diet = comprising a 750 kcal per day reduction from their calculated resting energy requirements. • Patients achieved >5% weight loss showed histological improvement. • 90% of those achieving >10% weight loss showed resolution of NASH after biopsy. Vilar-Gomez E, et al. Gastroenterology 2015; 149: 367–378.

  8. Calculation of Energy Requirement

  9. Calculation of Energy Requirement 1- What is Desirable Body Weight? • Actualbody weight: if BMI < 25 • Adjusted body weight : if BMI ≥ 25 Adjusted body weight = current weight - ideal body weight × 0.25 + ideal body weight

  10. Calculation of Energy Requirement 2- What is Ideal Body Weight? • To know how much excess weight an individual has • To know how many steps an individual needs to lose weight • To calculate adjusted ideal body weight • Usually it is BMI=22-23

  11. Calculation of Energy Requirement • Weight loss of 10% of total body weight over 6 months should be the initial goal. • For the next 4-6 months the focus changes from weight loss to weight maintenance. • Dietary changes include an energy deficit of 500-1000 kcal/day.

  12. Calculation of Energy Requirement

  13. Calculation of Energy Requirement Basal energy expenditure (BEE) Male BEE = 1  24 (hours)  desirable body weight (kg) Female BEE = 0.95  24 (hours)  desirable body weight (kg) Physical activity level (PAL) Very low: 30% BEE, Low: 50%, Moderate: 75%, High: 100% Thermogenic effect of food (TEF) 10% (BEE  energy for PAL) Total energy expenditure (TEE) = BEE  energy for PAL  TEF

  14. Example 1 Man with desirable body weight = 77 kg BEE: 1 × 24 × 77 = 1848kcal 1848 × 30% = 554 kcal 1848 + 554 = 2402 kcal 2402 × 10% = 240 kcal TEE = 1848 + 554 + 240 = 2642 ≈ 2650 kcal

  15. Calculation of Energy Requirement To simplify: Females TEE = DBW × 24 × 0.95 × 1.3 (1.2-2) × 1.1 Males TEE = DBW × 24 × 1.3 (1.2-2) × 1.1

  16. Example 2 28-year woman: • Wt = 86 kg • Ht = 164 cm • BMI = 32 • PAL = low

  17. Example 2 23 = IBW/(1.64)² IBW= 62 kg AIBW = (86 – 62) × 0.25 + 62 = 68 kg

  18. Example 2 TEE = 68 × 24 × 0.95 × 1.3 × 1.1 = 2139 kcal ≈ 2100 kcal 2100 – 500 = 1600 kcal 2100 کیلوکالری میزان انرژی مورد نیاز برای حفظ وزن است نه کاهش وزن 1600 کیلوکالری میزان انرژی مورد نیاز کاهش وزن تقریبا نیم کیلوگرمی در هفته است

  19. Composition of diet • In addition to total energy intake, the composition of the diet also affects metabolic and endocrine functions, and overall energy balance in NAFLD patients

  20. Composition of diet • Dietary carbohydrate content has been linked to heightened systemic inflammation and carbohydrate-restricted hypocaloric diets have been associated with greater reductions in hepatic steatosis than a general hypocaloric diet alone Browning JD, et al. Am J Clin Nutr 2011; 93: 048–1052. Browning JD, et al. Hepatology 2008; 48: 1487–1496. Oarada M, et al. Nutrition 2015; 31: 757–765.

  21. Composition of diet Rinella ME et al. Nat Rev Gastroenterol Hepatol 2016, 13, 196–205.

  22. Composition of diet • Reductions in the intake of fructose • Encourage consumption of diets rich in fruits and vegetables. • Such diets would provide a significant amount of bioactive components (polyphenols, anthocyanins, and resveratrol ) with known beneficial effects due, in part, to their anti-inflammatory and anti-oxidative properties

  23. Composition of diet • Reductions in the intake of total fat, saturated fatty acids, trans fatty acids, and cholesterol • Excess dietary cholesterol promotes hepatic de novo lipogenesisand increased levels of intracellular free cholesterol that can be cytotoxic

  24. Composition of diet

  25. Composition of diet Where do Trans fats come from?

  26. Composition of diet Saturated fat: Comparing different foods

  27. Fatty Acid Profiles of Fats and Oils

  28. Optimal Diet • Eating patterns: • Low carbohydrate • Low fat • Low GI (glycemic index) • Mediterranean (more vegetables, whole grains, fruit, legumes, nuts, fish, low-fat dairy, olive, and MUFA/PUFA; less red meat and SFAs) • Vegetarian

  29. Optimal Diet • Mediterranean diet effectively reduce hepatic steatosis when compared with an isocaloric low-fat, high-carbohydrate diet. • The beneficial effects of the Mediterranean diet on hepatic steatosis were independent of patient weight loss

  30. Coffee • To encourage patients to drink unsweetened coffee as part of lifestyle modifications to promote a healthy liver, as long as the patient does not have medical conditions that might be exacerbated by coffee intake.

  31. Carotenoids • Antioxidant micronutrients, such as vitamins and carotenoids, exist in abundance in fruits and vegetables and defend against reactive oxygen species • Carotenoids may participate in an antioxidant defense system when free radical species in the liver are present at high concentrations

  32. Synbiotic • Synbiotic supplementation in addition to lifestyle modification is superior to lifestyle modification alone for the treatment of NAFLD, at least partially through attenuation of inflammatory markers in the body Eslamparast T et al. Am J Clin Nutr 2014;99:535–42.

  33. Synbiotic

  34. Key Home Message • Lifestyle counseling • Gradual weight reduction • Limit carbohydrate to less than 45% energy intake • Limit simple sugars in particular fructose • Limit SFA, trans fatty acid, and cholesterol

  35. Thank you

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